Cirrhosis management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Cirrhosis management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Cirrhosis management US Medical PG Question 1: A 35-year-old woman seeks evaluation at a clinic with a complaint of right upper abdominal pain for greater than 1 month. She says that the sensation is more of discomfort than pain. She denies any history of weight loss, changes in bowel habit, or nausea. Her medical history is unremarkable. She takes oral contraceptive pills and multivitamins every day. Her physical examination reveals a palpable liver mass that is 2 cm in diameter just below the right costal margin in the midclavicular line. An abdominal CT scan reveals 2 hypervascular lesions in the right hepatic lobe. The serum α-fetoprotein level is within normal limits. What is the next best step in the management of this patient’s condition?
- A. Radiofrequency ablation (RFA)
- B. CT-guided biopsy
- C. Observation
- D. Referral for surgical excision
- E. Discontinue oral contraceptives (Correct Answer)
Cirrhosis management Explanation: **Discontinue oral contraceptives**
- The patient's presentation with a **palpable liver mass**, **hypervascular lesions** on CT, and history of **oral contraceptive pill (OCP) use** is highly suggestive of a **hepatic adenoma**.
- The first and most crucial step in managing hepatic adenomas is to **discontinue OCPs**, as this often leads to regression of the tumor.
*Referral for surgical excision*
- Surgical excision is considered for **large adenomas** (typically >5 cm), those that are **symptomatic** and do not regress after OCP cessation, or those with features suspicious for **malignant transformation**.
- While this patient has a palpable mass, its size (2 cm) does not immediately warrant surgical excision as a first line and observation after OCP cessation is preferred.
*CT-guided biopsy*
- **Biopsy** is generally **avoided** in suspected hepatic adenomas due to the risk of **hemorrhage** from these highly vascular lesions and the potential for false negatives due to tumor heterogeneity.
- The diagnosis is usually made clinically with imaging and reversal upon stopping OCPs.
*Radiofrequency ablation (RFA)*
- **RFA** is a local ablative therapy typically reserved for cases where surgery is contraindicated or for specific types of **unresectable tumors**, often in the context of hepatocellular carcinoma or metastatic disease.
- It is not the initial treatment for an unconfirmed hepatic adenoma, especially before attempting OCP cessation.
*Observation*
- While observation is part of the management, it only follows **discontinuation of OCPs** and involves serial imaging to monitor for regression or growth.
- Simply observing the patient without addressing the potential precipitating factor (OCPs) is not the best initial step.
Cirrhosis management US Medical PG Question 2: A 65-year-old man with decompensated cirrhosis secondary to hepatitis C is brought to the emergency department with 2 episodes of massive hematemesis that started 2 hours ago. He is a liver transplant candidate. The blood pressure is 110/85 mm Hg in the supine position and 90/70 mm Hg after sitting for 3 minutes. The pulse is 110/min, the respirations are 22/min, and the temperature is 36.1°C (97.0°F). The physical examination shows spider angiomata, palmar erythema, and symmetric abdominal distension with positive shifting dullness. The lung and heart examination shows no abnormalities. Two large-bore intravenous lines are obtained. Saline (0.9%) is initiated. Laboratory tests are pending. The most important next step is to administer which of the following intravenous therapies?
- A. Fresh frozen plasma
- B. Octreotide (Correct Answer)
- C. Packed red blood cells (RBCs)
- D. Propranolol
- E. Pantoprazole
Cirrhosis management Explanation: ***Octreotide***
- This patient's presentation with **massive hematemesis**, **decompensated cirrhosis**, and signs of portal hypertension strongly suggests **esophageal variceal bleeding**.
- **Octreotide**, a somatostatin analog, is critical in managing variceal bleeding by causing **splanchnic vasoconstriction**, which reduces portal blood flow and pressure, thereby decreasing active bleeding.
*Fresh frozen plasma*
- While patients with **cirrhosis often have coagulopathy**, administering fresh frozen plasma (FFP) without documented severe coagulopathy or active bleeding requiring immediate reversal (e.g., before an invasive procedure) is not the highest priority.
- **FFP transfusions** can paradoxically increase portal pressure and volume, potentially worsening variceal bleeding.
*Packed red blood cells (RBCs)*
- Though the patient is likely anemic due to massive hematemesis, **transfusion of RBCs** should be guided by hemoglobin levels and clinical signs of hemodynamic instability, with a goal to achieve **hemodynamic stability** rather than over-transfusing.
- While important, **stopping the bleeding** with octreotide takes precedence before optimal RBC transfusion thresholds are determined.
*Propranolol*
- **Propranolol** is a non-selective beta-blocker used for **primary and secondary prophylaxis** of variceal bleeding.
- It is **contraindicated in acute bleeding** as it can worsen hypotension and interfere with the body's compensatory mechanisms during hypovolemic shock.
*Pantoprazole*
- **Pantoprazole**, a **proton pump inhibitor (PPI)**, is used to suppress stomach acid and is beneficial in managing **peptic ulcer bleeding**.
- However, it has no direct role in controlling **variceal bleeding**, which originates from esophageal varices rather than acid-related gastric or duodenal mucosa.
Cirrhosis management US Medical PG Question 3: A 56-year-old woman is brought to the emergency department by her family with altered mental status. Her husband says that she complained of fever, vomiting, and abdominal pain 2 days ago. She has a history of long-standing alcoholism and previous episodes of hepatic encephalopathy. Current vital signs include a temperature of 38.3°C (101°F), blood pressure of 85/60 mm Hg, pulse of 95/min, and a respiratory rate 30/min. On physical examination, the patient appears ill and obtunded. She is noted to have jaundice, a palpable firm liver, and massive abdominal distension with shifting dullness. Which of the following is the best initial step in management of this patient's condition?
- A. Empiric antibiotics (Correct Answer)
- B. Diagnostic paracentesis
- C. Large volume paracentesis
- D. Intravenous albumin
- E. Non-selective beta-blockers
Cirrhosis management Explanation: ***Empiric antibiotics***
- This patient presents with **altered mental status**, **fever**, **hypotension (85/60 mm Hg)**, **tachypnea**, and **massive ascites** in the setting of **cirrhosis**, indicating **suspected spontaneous bacterial peritonitis (SBP) with septic shock**.
- In a **hemodynamically unstable patient** with suspected SBP, **empiric antibiotics** (typically a third-generation cephalosporin like ceftriaxone or cefotaxime) should be initiated **immediately** without waiting for diagnostic paracentesis results.
- Current **AASLD and EASL guidelines** emphasize that antibiotic therapy should not be delayed in critically ill patients, as early treatment significantly reduces mortality in SBP.
- Diagnostic paracentesis should still be performed urgently but should **not delay antibiotic administration** in this unstable patient.
*Diagnostic paracentesis*
- While **diagnostic paracentesis** is the gold standard for confirming SBP and should be performed promptly, it is not the **best initial step** in a hemodynamically unstable patient.
- In this critically ill patient with septic shock, obtaining ascitic fluid can be done **simultaneously with** or **immediately after** starting antibiotics, but antibiotics take priority.
- If the patient were stable, diagnostic paracentesis before antibiotics would be appropriate to guide therapy.
*Large volume paracentesis*
- **Large volume paracentesis** is indicated for symptomatic relief of tense ascites causing respiratory compromise, not as an initial step in suspected infection.
- In the setting of suspected SBP, only diagnostic paracentesis (50-100 mL) is needed initially, not large volume removal.
*Intravenous albumin*
- **Intravenous albumin** is given as adjunctive therapy in SBP patients with **renal dysfunction** (creatinine >1 mg/dL, BUN >30 mg/dL) or **hypotension** to prevent hepatorenal syndrome.
- While this patient may benefit from albumin, it is not the **initial step**—antibiotics and fluid resuscitation take priority.
- Albumin is typically given at 1.5 g/kg within 6 hours and 1 g/kg on day 3.
*Non-selective beta-blockers*
- **Non-selective beta-blockers** (propranolol, nadolol) are used for **primary and secondary prophylaxis of variceal bleeding** in portal hypertension.
- They are **contraindicated** in patients with **hypotension** (BP 85/60 mm Hg), **sepsis**, or **SBP**, as they can worsen hemodynamic instability.
- Recent studies suggest beta-blockers may be harmful in patients with refractory ascites or SBP.
Cirrhosis management US Medical PG Question 4: An epidemiologist is evaluating the efficacy of Noxbinle in preventing HCC deaths at the population level. A clinical trial shows that over 5 years, the mortality rate from HCC was 25% in the control group and 15% in patients treated with Noxbinle 100 mg daily. Based on this data, how many patients need to be treated with Noxbinle 100 mg to prevent, on average, one death from HCC?
- A. 20
- B. 73
- C. 10 (Correct Answer)
- D. 50
- E. 100
Cirrhosis management Explanation: ***10***
- The **number needed to treat (NNT)** is calculated by first finding the **absolute risk reduction (ARR)**.
- **ARR** = Risk in control group - Risk in treatment group = 25% - 15% = **10%** (or 0.10).
- **NNT = 1 / ARR** = 1 / 0.10 = **10 patients**.
- This means that **10 patients must be treated with Noxbinle to prevent one death from HCC** over 5 years.
*20*
- This would result from an ARR of 5% (1/0.05 = 20), which is not supported by the data.
- May arise from miscalculating the risk difference or incorrectly halving the actual ARR.
*73*
- This value does not correspond to any standard calculation of NNT from the given mortality rates.
- May result from confusion with other epidemiological measures or calculation error.
*50*
- This would correspond to an ARR of 2% (1/0.02 = 50), which significantly underestimates the actual risk reduction.
- Could result from incorrectly calculating the difference as a proportion rather than absolute percentage points.
*100*
- This would correspond to an ARR of 1% (1/0.01 = 100), grossly underestimating the treatment benefit.
- May result from confusing ARR with relative risk reduction or other calculation errors.
Cirrhosis management US Medical PG Question 5: A 52-year-old man comes to the physician because of progressive abdominal distention and weight gain over the last 2 months. He was diagnosed with alcoholic liver cirrhosis with large ascites 1 year ago. He has congestive heart failure with a depressed ejection fraction related to his alcohol use. For the last 6 months, he has abstained from alcohol and has followed a low-sodium diet. His current medications include propranolol, spironolactone, and furosemide. His temperature is 36.7°C (98°F), pulse is 90/min, and blood pressure is 109/56 mm Hg. Physical examination shows reddening of the palms, telangiectasias on the face and trunk, and prominent blood vessels around the umbilicus. The abdomen is tense and distended; there is no abdominal tenderness. On percussion of the abdomen, there is dullness that shifts when the patient moves from the supine to the right lateral decubitus position. When the patient stretches out his arms with the wrists extended, a jerky, flapping motion of the hands is seen. Mental status examination shows a decreased attention span. Serum studies show:
Sodium 136 mEq/L
Creatinine 0.9 mg/dL
Albumin 3.6 mg/dL
Total bilirubin 1.9 mg/dL
INR 1.0
Which of the following is the most appropriate next step in treatment?
- A. Refer for liver transplantation
- B. Perform large-volume paracentesis (Correct Answer)
- C. Refer for peritoneovenous shunt
- D. Change propranolol to carvedilol
- E. Refer for transjugular intrahepatic portosystemic shunt
Cirrhosis management Explanation: ***Perform large-volume paracentesis***
- The patient presents with **tense, distended ascites** refractory to diuretics and a low-sodium diet, evidenced by progressive abdominal distention and weight gain despite current management. **Large-volume paracentesis** is the most effective approach for immediate symptomatic relief
- The patient's clinical picture includes signs of **hepatic encephalopathy** (decreased attention span, asterixis) and **decompensated cirrhosis** (ascites, portal hypertension signs), but the immediate priority is to relieve the discomfort and respiratory compromise associated with large ascites.
*Refer for liver transplantation*
- While ultimately this patient may be a candidate for a **liver transplant** due to decompensated cirrhosis, it is not the immediate next step for managing **symptomatic tense ascites**.
- Liver transplantation involves extensive evaluation and a waiting period, and the acute issue needs to be addressed first.
*Refer for peritoneovenous shunt*
- **Peritoneovenous shunts** are rarely used due to high complication rates, including shunt thrombosis, infection, and disseminated intravascular coagulation.
- They are considered only in cases of **refractory ascites** where paracentesis is not feasible or effective long-term, which is not the case here as paracentesis has not been attempted for the current increase in ascites.
*Change propranolol to carvedilol*
- Both **propranolol** and **carvedilol** are non-selective beta-blockers used to reduce portal pressure, but **carvedilol** has additional alpha-1 blocking properties that may offer slightly more hemodynamic effects.
- However, switching beta-blockers will not directly address the immediate issue of **tense ascites** and could potentially worsen **hypotension** given the current blood pressure of 109/56 mm Hg.
*Refer for transjugular intrahepatic portosystemic shunt*
- A **TIPS** procedure is considered for **refractory ascites** that does not respond to repeated large-volume paracentesis and aggressive diuretic therapy.
- Given that a large-volume paracentesis has not been performed for the current exacerbation, **TIPS** would be a premature intervention and is associated with risks such as worsening hepatic encephalopathy.
Cirrhosis management US Medical PG Question 6: A 54-year-old woman comes to the physician with abdominal distention and mild diffuse abdominal discomfort. She has not had nausea, vomiting, fever, or chills. She was diagnosed with alcoholic liver cirrhosis 2 years ago. Examination shows a protruding, distended abdomen that is dull to percussion with a positive fluid wave. Ultrasonography shows mild to moderate ascites. Appropriate treatment of the patient's condition is started. Four days later, the patient experiences palpitations and chest pain at home. She is brought to the emergency department, where her temperature is 37.3°C (99.1°F), pulse is 182/min, respirations are 18/min, and blood pressure is 82/50 mm Hg. An ECG shows ventricular tachycardia. Initial laboratory studies show:
Serum
Na+ 131 mEq/L
K+ 2.9 mEq/L
Cl- 92 mEq/L
Bicarbonate 34 mEq/L
Urea nitrogen 42 mg/dL
Creatinine 4.8 mg/dL
Glucose 90 mg/dL
Ca2+ 8.1 mg/dL
Mg2+ 1.5 mg/dL
Phosphate 4.7 mg/dL
Arterial Blood Gas
pH 7.52
pCO2 45 mm Hg
pO2 90.2 mm Hg
She is successfully cardioverted to normal sinus rhythm. Which of the following treatments is most likely responsible for this patient's presentation?
- A. Lisinopril
- B. Acetazolamide
- C. Mannitol
- D. Furosemide (Correct Answer)
- E. Hydrochlorothiazide
Cirrhosis management Explanation: ***Furosemide***
- The patient's **hypokalemia (2.9 mEq/L)**, **hypomagnesemia (1.5 mg/dL)**, and **metabolic alkalosis (pH 7.52, bicarbonate 34 mEq/L)** are characteristic side effects of **loop diuretics** like furosemide.
- These electrolyte imbalances, particularly **hypokalemia** and **hypomagnesemia**, can predispose to serious cardiac arrhythmias such as **ventricular tachycardia**, which the patient experienced.
- Loop diuretics are commonly used in combination with spironolactone for management of cirrhotic ascites.
*Lisinopril*
- Lisinopril is an **ACE inhibitor** and would typically cause **hyperkalemia**, not hypokalemia, due to its effect on aldosterone.
- It works by vasodilation and could potentially worsen hypotension, but it doesn't explain the patient's specific electrolyte disturbances or arrhythmia profile.
*Acetazolamide*
- Acetazolamide is a **carbonic anhydrase inhibitor** that can cause **metabolic acidosis** and hypokalemia but would not lead to the metabolic alkalosis observed here.
- It increases bicarbonate excretion, which is the opposite of this patient's acid-base status.
*Mannitol*
- Mannitol is an **osmotic diuretic** primarily used for cerebral edema or acute glaucoma.
- Its main effects relate to fluid shifts, and while it could cause electrolyte disturbances, it's not typically associated with this specific constellation of hypokalemia, hypomagnesemia, and metabolic alkalosis.
*Hydrochlorothiazide*
- Hydrochlorothiazide is a **thiazide diuretic** that can cause hypokalemia, hypomagnesemia, and metabolic alkalosis, similar to loop diuretics.
- However, **thiazides are not used for cirrhotic ascites** because they are ineffective in treating significant fluid overload and can worsen complications of cirrhosis. The standard treatment is spironolactone (aldosterone antagonist) with or without a loop diuretic like furosemide for refractory cases.
Cirrhosis management US Medical PG Question 7: A 48-year-old man comes to the physician because of increasing generalized fatigue for 1 month. He has been unable to do normal household duties or go for his evening walks during this period. He has hypertension, hyperlipidemia, and type 2 diabetes mellitus. His father died of liver cancer at the age of 60 years. He does not smoke. He drinks one alcoholic beverage daily. Current medications include atorvastatin, enalapril, metformin, and insulin glargine. He is 170 cm (5 ft 7 in) tall and weighs 100 kg (220 lb); BMI is 34.6 kg/m2. His temperature is 36.6°C (97.9°F), pulse is 116/min, and blood pressure is 140/90 mm Hg. Examination shows hyperpigmented skin over the nape of the neck and extremities. The liver is palpated 4 cm below the right costal margin. Laboratory studies show:
Hemoglobin 10.6 g/dL
Mean corpuscular volume 87 μm3
Leukocyte count 9,700/mm3
Platelet count 182,000/mm3
Serum
Glucose 213 mg/dL
Creatinine 1.4 mg/dL
Albumin 4.1 g/dL
Total bilirubin 1.1 mg/dL
Alkaline phosphatase 66 U/L
AST 100 U/L
ALT 69 U/L
γ-glutamyl transferase 28 U/L (N=5–50)
Hepatitis B surface antigen negative
Hepatitis C antibody negative
Iron studies
Iron 261 μg/dL
Ferritin 558 ng/dL
Transferrin saturation 83%
Anti-nuclear antibody negative
Which of the following is the most appropriate next step to confirm the diagnosis?
- A. Abdominal ultrasonography
- B. CT of the abdomen
- C. Bone marrow biopsy
- D. Liver biopsy
- E. Genetic testing (Correct Answer)
Cirrhosis management Explanation: ***Genetic testing***
- The patient's **elevated iron (261 μg/dL), ferritin (558 ng/dL), and transferrin saturation (83%)**, along with **hyperpigmented skin**, **hepatomegaly**, and a family history of liver cancer, are highly suggestive of **hereditary hemochromatosis**.
- **Genetic testing for HFE gene mutations (C282Y and H63D)** is the **current first-line confirmatory test** per AASLD guidelines when hereditary hemochromatosis is suspected with elevated iron studies.
- **C282Y homozygosity** accounts for ~85-90% of hereditary hemochromatosis cases in Caucasian populations.
*Abdominal ultrasonography*
- While ultrasound can show **hepatomegaly** and assess for liver masses (important given family history of liver cancer), it is **not specific for hemochromatosis**.
- It cannot differentiate hemochromatosis from other causes of liver enlargement or provide information about the underlying cause of iron overload.
*CT of the abdomen*
- CT can show increased liver density due to **iron deposition** in hemochromatosis, but this finding is **neither sensitive nor specific** enough for diagnosis.
- It involves radiation exposure and is less definitive than **genetic testing** for confirming hereditary hemochromatosis.
*Bone marrow biopsy*
- Bone marrow biopsy evaluates **hematologic disorders** and can assess reticuloendothelial iron stores, but this is **not the site of pathologic iron accumulation** in hemochromatosis.
- In hemochromatosis, iron accumulates in **parenchymal cells** (liver, pancreas, heart, pituitary), not primarily in bone marrow macrophages.
- This invasive procedure is not indicated for diagnosing hemochromatosis.
*Liver biopsy*
- Liver biopsy with **Prussian blue staining** and hepatic iron concentration measurement was historically the gold standard for diagnosis.
- Today, liver biopsy is **reserved for staging** (assessing degree of fibrosis/cirrhosis) or when **non-HFE hemochromatosis** is suspected after negative genetic testing.
- Given strong biochemical evidence and availability of non-invasive genetic testing, biopsy is not the initial confirmatory test.
Cirrhosis management US Medical PG Question 8: A 54-year-old man with alcoholism comes to the emergency department because of vomiting blood for 6 hours. He has had 3–4 episodes in which he has vomited dark red blood during this period. He has had no epigastric pain or tarry stools. On arrival, his temperature is 37.3°C (99.1°F), pulse is 134/min, and blood pressure is 80/50 mm Hg. He is resuscitated with 0.9% saline and undergoes an emergency upper endoscopy, which shows actively bleeding varices. Band ligation of the varices is done and hemostasis is achieved. He is diagnosed with Child class B cirrhosis. He is concerned about the possibility of recurrence of such an episode. He is asked to abstain from alcohol, to which he readily agrees. In addition to non-selective beta-blocker therapy, which of the following is the most appropriate recommendation to prevent future morbidity and mortality from this condition?
- A. Terlipressin
- B. Transjugular intrahepatic portosystemic shunt
- C. Variceal sclerotherapy
- D. Variceal ligation (Correct Answer)
- E. Octreotide therapy
Cirrhosis management Explanation: ***Variceal ligation***
- **Endoscopic variceal ligation (EVL) is the gold standard for secondary prophylaxis** (preventing re-bleeding) in patients who have already experienced a variceal hemorrhage.
- It involves placing elastic bands on varices to occlude them, leading to fibrosis and eradication of the varices.
*Terlipressin*
- **Terlipressin is a vasoconstrictor primarily used to control acute variceal bleeding**, not for long-term secondary prevention.
- It reduces portal pressure by causing splanchnic vasoconstriction but is not suitable for chronic management.
*Transjugular intrahepatic portosystemic shunt*
- **TIPS is typically reserved for patients who fail endoscopic and pharmacological therapies** or have refractory ascites.
- While effective in reducing portal pressure, it carries risks such as **hepatic encephalopathy** and is not the first-line secondary prevention strategy.
*Variceal sclerotherapy*
- **Variceal sclerotherapy involves injecting a sclerosant solution into or adjacent to varices to induce thrombosis and fibrosis.**
- It is an alternative to band ligation but is generally **less preferred for secondary prophylaxis due to a higher rate of complications** like esophageal ulceration and re-bleeding.
*Octreotide therapy*
- **Octreotide, a somatostatin analog, is used to reduce splanchnic blood flow and portal pressure during acute variceal bleeding episodes.**
- It is **not recommended for long-term secondary prophylaxis** and is typically used in conjunction with endoscopic therapy for acute management.
Cirrhosis management US Medical PG Question 9: A 55-year-old man presents to urgent care for weakness and weight loss. He states for the past several months he has felt progressively weaker and has lost 25 pounds. The patient also endorses intermittent abdominal pain. The patient has not seen a physician in 30 years and recalls being current on most of his vaccinations. He says that a few years ago, he went to the emergency department due to abdominal pain and was found to have increased liver enzymes due to excessive alcohol use and incidental gallstones. The patient has a 50 pack-year smoking history. His temperature is 99.5°F (37.5°C), blood pressure is 161/108 mmHg, pulse is 90/min, respirations are 17/min, and oxygen saturation is 95% on room air. Physical exam reveals an emaciated man. The patient has a negative Murphy's sign and his abdomen is non-tender. Cardiopulmonary exam is within normal limits. Which of the following is the next best step in management?
- A. CT scan of the abdomen (Correct Answer)
- B. CT scan of the liver
- C. Right upper quadrant ultrasound
- D. HIDA scan
- E. Smoking cessation advice and primary care follow up
Cirrhosis management Explanation: ***CT scan of the abdomen***
- The patient presents with **constitutional symptoms** (weakness, significant weight loss), **intermittent abdominal pain**, and a **50 pack-year smoking history**, which are red flags for potential **malignancy**.
- A CT scan of the abdomen is the most appropriate initial imaging study to **evaluate for masses, metastases, or other pathologies** that would explain these symptoms comprehensively.
*CT scan of the liver*
- While the patient has a history of elevated liver enzymes and gallstones, focusing solely on the liver might **miss other abdominal pathologies** that could explain his symptoms.
- A CT of the liver is a more targeted scan, usually performed after a broader abdominal assessment suggests a primary liver issue.
*Right upper quadrant ultrasound*
- An ultrasound of the right upper quadrant is excellent for evaluating the **gallbladder, bile ducts, and liver parenchyma** for stones, cholecystitis, or focal lesions.
- However, it has **limited ability to visualize the retroperitoneum, pancreas, or other bowel structures** which could be the source of the patient's symptoms.
*HIDA scan*
- A HIDA scan is used to assess **gallbladder function** and is primarily indicated for suspected **acute cholecystitis** when ultrasound findings are equivocal, or for chronic gallbladder dysfunction.
- The patient's presentation of generalized weakness, significant weight loss, and non-tender abdomen does not acutely point towards biliary obstruction or acute cholecystitis.
*Smoking cessation advice and primary care follow up*
- While **smoking cessation** is crucial for long-term health, and **primary care follow-up** is necessary, these steps are not the *next best step in management* for a patient presenting with alarming symptoms of weakness, significant weight loss, and abdominal pain.
- These are important secondary measures, but the immediate concern is to **investigate the cause of his current severe symptoms**.
Cirrhosis management US Medical PG Question 10: A 49-year-old man presents to the emergency department with abdominal discomfort, fever, and decreased urination. He has a history of liver cirrhosis due to chronic hepatitis C infection. His blood pressure is 90/70 mm Hg, pulse is 75/min, and temperature 38°C (100.4°F). On physical examination he is jaundiced, and he has tense ascites with generalized abdominal tenderness. There is pitting edema to the level of his upper thighs. Which of the following excludes the diagnosis of hepatorenal syndrome in this patient?
- A. Low albumin levels
- B. Normal renal ultrasound
- C. Presence of 30 red cells/high powered field in the urine (Correct Answer)
- D. Low urea levels
- E. Prolonged prothrombin time
Cirrhosis management Explanation: ***Presence of 30 red cells/high powered field in the urine***
- **Hepatorenal syndrome (HRS)** is a diagnosis of exclusion characterized by **functional renal failure** in the setting of severe liver disease without intrinsic renal pathology. The presence of significant red blood cells in the urine (e.g., >50 RBCs/HPF is a more definitive cutoff often used, but 30 RBCs/HPF is highly suspicious) indicates an **intrinsic renal problem**, such as glomerulonephritis or acute tubular necrosis, which would exclude HRS.
- HRS typically presents with **benign urinary sediment**, meaning few or no red blood cells, white blood cells, or casts, as the kidneys themselves are structurally intact.
*Low albumin levels*
- **Hypoalbuminemia** is a common finding in patients with **cirrhosis** due to impaired hepatic synthesis and is often associated with ascites and edema.
- It is a predisposing factor for HRS development, but its presence does not exclude or confirm the diagnosis.
*Normal renal ultrasound*
- A **normal renal ultrasound** indicates the absence of **structural kidney disease** (e.g., obstruction, polycystic kidneys, or severe chronic kidney disease) that could otherwise explain the renal failure.
- This finding is **consistent with HRS**, as HRS is a functional renal failure without gross renal structural abnormalities, thus it does not exclude the diagnosis.
*Low urea levels*
- **Urea synthesis occurs in the liver**, and in patients with severe **cirrhosis**, the liver's ability to produce urea from ammonia may be impaired.
- Therefore, **low urea levels (or disproportionately low BUN relative to creatinine)** can be seen in advanced liver disease, even with renal impairment, and do not exclude HRS.
*Prolonged prothrombin time*
- A **prolonged prothrombin time (PT)** is a hallmark of severe **liver dysfunction** due to reduced synthesis of coagulation factors.
- It indicates the severity of the underlying liver disease and is a common finding in patients who develop HRS, therefore, it does not exclude the diagnosis.
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